Utilization Management Physician Reviewer
3 weeks ago
Check below to see if you have what is needed for this opportunity, and if so, make an application asap.
Title: Full-Time Utilization Management Physician Reviewer
Location: Remote/ Treehouse
Role Description:
This full-time role is responsible for provisioning accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management (UM) criteria, clinical judgment, and internal policies and procedures. Regardless of the final determination, the Physician Reviewer is responsible for ensuring medically appropriate care is recommended to the patient and their care team, which may require coordination with internal and external parties including, but not limited to: requesting providers, external UM and case management staff, internal transitional care managers, employed primary care providers, and regional medical leaders. We strive for clinical excellence and ensuring our patients receive the right care, in the right setting, at the right time.
Core Responsibilities:
Review service requests and document the rationale for the decision in easy to understand language per Oak Street Health policies and procedures and industry standards; types of requests include but not limited to: Acute, Post-Acute, and Pre-service (Expedited, Standard, and Retrospective)
Use evidence-based criteria and clinical reasoning to make UM determinations in concert with an enrolleeâs individual conditions and situation. OSH does not solely make authorization determinations based on criteria, but uses it as a tool to assist in decision making.
Work collaboratively with the Oak Street Health Transitional Care and PCP care teams to drive efficient and effective care delivery to patients
Maintain knowledge of current CMS and MCG evidence-based guidelines to enable UM decisions
Maintain compliance with legal, regulatory and accreditation requirements and payor partner policies
Participate in initiatives to achieve and improve UM imperatives; for example, participate in committees or work-groups to help advance UM efforts at Oak Street and promote a culture of continuous quality improvement
Assist in formal responses to health plan regarding UM process or specific determinations on an as-needed basis
Adhere to regulatory and accreditation requirements of payor partners (e.g., site visits from regulatory & accreditation agencies, responses to inquiries from regulatory and accreditation agencies and payor partners, etc.)
Participate in rounding and patient panel management discussions as required
Fulfill on-call requirement, should the need arise
Other duties, as required and assigned
What are we looking for?
At least one year experience providing Utilization Management services to a Medicare and/or Medicaid line of business
Excellent verbal and written communication skills
A current, clinical, unrestricted license to practice medicine in the United States. (NCQA Standard)
Graduate of an accredited medical school. M.D. or D.O. Degree is required. (NCQA Standard)
3-5 years of clinical practice in a primary care setting
Deep understanding of managed care, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, and pharmacy management
Strong record of continuing education activities (relevant to practice area and needed to maintain licensure)
Demonstrated understanding of culturally responsive care
Proven organizational and detail-orientation skills
US work authorization
Someone who embodies being Oaky
What does being Oaky look like?
Radiating positive energy
Assuming good intentions
Creating an unmatched patient experience
Driving clinical excellence
Taking ownership and delivering results
Being relentlessly determined
Why Oak Street Health?
Oak Street Health is on a mission to Rebuild healthcare as it should be, providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patientâs communities, and focused on the quality of care over volume of services. Weâre an organization on the move With over 150 locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oaky values and passion for our mission.
Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.
Learn more at www.oakstreethealth.com/diversity-equity-and-inclusion-at-oak-street-health
-
Physician Reviewer for Utilization Management
2 weeks ago
Chicago, Illinois, United States Oak Street Health Full timeCompany: Oak Street Health Title: Full-Time Utilization Management Physician Reviewer Location: Remote/ Treehouse Role Overview: This full-time position is dedicated to delivering precise and prompt coverage decisions for both inpatient and outpatient services by utilizing utilization management (UM) criteria, clinical expertise, and established internal...
-
Utilization Management Physician Reviewer
3 weeks ago
Chicago, United States Oak Street Health Full timeCompany: Oak Street HealthTitle: Full-Time Utilization Management Physician ReviewerLocation: Remote/ TreehouseRole Description:This full-time role is responsible for provisioning accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management (UM) criteria, clinical judgment, and internal policies and...
-
Utilization Management Physician Reviewer
4 weeks ago
Chicago, United States Oak Street Health Full timeDescription Company: Oak Street Health Title: Full-Time Utilization Management Physician Reviewer Location: Remote/ Treehouse Role Description: This full-time role is responsible for provisioning accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management (UM) criteria, clinical judgment, and internal...
-
Utilization Management Physician Reviewer
3 weeks ago
Chicago, United States Oak Street Health Full timeCompany: Oak Street Health Title: Full-Time Utilization Management Physician Reviewer Location: Remote/ Treehouse Role Description: This full-time role is responsible for provisioning accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management (UM) criteria, clinical judgment, and internal policies and...
-
Utilization Management Physician Reviewer
4 weeks ago
Chicago, IL, United States Oak Street Health Full timeCompany: Oak Street HealthTitle: Full-Time Utilization Management Physician ReviewerLocation: Remote/ TreehouseRole Description:This full-time role is responsible for provisioning accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management (UM) criteria, clinical judgment, and internal policies and...
-
Clinical Utilization Review Specialist
2 weeks ago
Chicago, Illinois, United States Rising Medical Solutions Full timeCompany OverviewRising Medical Solutions is dedicated to transforming the healthcare landscape by enhancing the efficiency of healthcare claims through comprehensive bill review, case management, and utilization review. Position SummaryWe are currently seeking a qualified Utilization Review Nurse to join our team. This full-time role requires a commitment of...
-
Clinical Utilization Review Specialist
4 days ago
Chicago, Illinois, United States Centene Corporation Full timeJob SummaryWe are seeking a highly skilled Clinical Utilization Review Specialist to join our Medical Management/Health Services team at Centene Corporation. As a key member of our team, you will play a critical role in ensuring the quality and appropriateness of mental health and substance abuse services for our 28 million members.Key...
-
Physician Reviewer
7 days ago
Chicago, Illinois, United States Dane Street, LLC Full timeAbout the RoleDane Street, LLC is seeking a Board Certified Internal Medicine physician to conduct Independent Medical Exams (IMEs) and Peer Reviews. As a medical reviewer, you will utilize your clinical expertise to review disability claims and provide an interpretation of the medical appropriateness of services provided by other healthcare...
-
Physician Reviewer
3 months ago
Chicago, United States w3r Consulting Full timeDescription: This position requires an initial time commitment to undergo and complete training. After training, physician medical reviewer will provide weekend coverage, 8 hour shifts per Saturday and/or Sunday per month. This is a remote position. Physician medical reviewer evaluates clinical service requests based on company guidelines to make medical...
-
Utilization Review Clinician
4 weeks ago
Chicago, United States Centene Corporation Full timeYou could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. ****NOTE: This is a fully remote role for US based applicants with...
-
Utilization Management Coordinator
4 weeks ago
Chicago, Illinois, United States Universal Health Services, Inc. Full timeResponsibilities Offering $3000 sign-on bonus JOB SUMMARY: Performs timely, daily clinical reviews with all payer types, to secure authorization for initial and continued treatment based on payer's criteria and in accordance with the hospital wide Utilization Management Plan. Serves as liaison to 3rd and 4th party reviewers, effectively coordinating...
-
Utilization Management Coordinator
2 months ago
Chicago, United States UHS Full timeResponsibilities JOB SUMMARY: Performs timely, daily clinical reviews with all payer types, to secure authorization for initial and continued treatment based on payer's criteria and in accordance with the hospital wide Utilization Management Plan. Serves as liaison to 3rd and 4th party reviewers, effectively coordinating collection of all supporting data to...
-
Utilization Management Coordinator
4 weeks ago
Chicago, United States UHS Full timeResponsibilities Offering $3000 sign-on bonus! JOB SUMMARY: Performs timely, daily clinical reviews with all payer types, to secure authorization for initial and continued treatment based on payer's criteria and in accordance with the hospital wide Utilization Management Plan. Serves as liaison to 3rd and 4th party reviewers, effectively coordinating...
-
Utilization Management Coordinator
4 weeks ago
Chicago, United States Universal Health Services, Inc. Full timeResponsibilities Offering $3000 sign-on bonus! JOB SUMMARY: Performs timely, daily clinical reviews with all payer types, to secure authorization for initial and continued treatment based on payer's criteria and in accordance with the hospital wide Utilization Management Plan. Serves as liaison to 3rd and 4th party reviewers, effectively coordinating...
-
Utilization Management Specialist
2 weeks ago
Chicago, Illinois, United States Health Care Service Corporation Full timeAt Health Care Service Corporation (HCSC), our workforce is the foundation of our operations and the key to our achievements. We equip our team members with tailored development strategies that encourage advancement and support rewarding, meaningful careers. Position Overview This role is accountable for conducting initial and ongoing review processes;...
-
Utilization Management Specialist
2 weeks ago
Chicago, Illinois, United States Health Care Service Corporation Full timeAt Health Care Service Corporation, our workforce is integral to our mission and the key to our achievements. We equip our team members with tailored development strategies that encourage advancement and support rewarding, meaningful careers. Position Overview This role entails conducting initial and ongoing review processes; coordinating discharge care to...
-
Medical Review Specialist
2 weeks ago
Chicago, Illinois, United States Dane Street, LLC Full timeDane Street, LLC, recognized as a certified "Great Place to Work," is actively seeking Board Certified Internal Medicine physicians to engage in Independent Medical Exams (IME) and Peer Reviews. This role offers the flexibility to tailor your schedule and caseload within a conventional Monday to Friday workweek while adhering to client-mandated turnaround...
-
Utilization Management Specialist
1 week ago
Chicago, Illinois, United States Health Care Service Corporation Full timeAt Health Care Service Corporation, our workforce is the foundation of our operations and the key to our achievements. We equip our team members with tailored development plans that encourage advancement and foster rewarding, fulfilling careers. Position Overview This role is pivotal in executing initial and ongoing review processes, as well as coordinating...
-
Medical Review Specialist
2 weeks ago
Chicago, Illinois, United States Dane Street, LLC Full timeDane Street, LLC, recognized as a certified "Great Place to Work," is actively seeking Board Certified Internal Medicine physicians to perform Independent Medical Exams (IME) and Peer Reviews. This role offers the flexibility to tailor your schedule and caseload within a standard Monday to Friday workweek while adhering to client-mandated turnaround times.As...
-
Medical Review Specialist
1 week ago
Chicago, Illinois, United States Dane Street, LLC Full timeDane Street, LLC, recognized as a certified "Great Place to Work," is seeking Board Certified Internal Medicine physicians to perform Independent Medical Exams (IME) and Peer Reviews. This role offers the flexibility to tailor your schedule and caseload within a standard Monday to Friday work week while adhering to client-mandated turnaround times.As a...
